Healthcare Provider Details

I. General information

NPI: 1053054304
Provider Name (Legal Business Name): DEAYA SALEH DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2022
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 OAK PARK AVE
BERWYN IL
60402-2220
US

IV. Provider business mailing address

7042 BREMENTOWNE RD
TINLEY PARK IL
60477-1639
US

V. Phone/Fax

Practice location:
  • Phone: 708-218-9642
  • Fax:
Mailing address:
  • Phone: 708-691-2723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.033645
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: